The Impact of Peer Management on Test-Ordering Behavior

Context Can simple electronic aids help physicians reduce unnecessary, costly test ordering? Contribution In this interrupted time-series study from a large academic hospital, a committee of peer leaders selected ways to use their care provider order entry (CPOE) system to reduce unnecessary test ordering. Computer prompts questioning repetitive orders for routine tests and unbundling of tests within metabolic panel tests both reduced test orders. Patient readmission rates, length of stay, transfer to intensive care units, and mortality rates remained stable. Implications Peer-designed interventions using CPOE systems can improve provider test-ordering behavior. The Editors Providers of clinical care order excessive tests for hospitalized patients for defensive reasons (1) or ease of access (2) or because they cannot manage the fear of uncertainty (3, 4). Excessive ordering increases the use of technology and adds unnecessary costs to the delivery of health care. Motivated by studies demonstrating substantial variation in testing behaviors among providers (2, 5-14), inappropriate or unnecessary testing (15-23), and test addiction (24-26), investigators over the past decade have tried to impose sustainable limits on diagnostic evaluations. However, many recommended approaches are too time-consuming (27), difficult to scale across an institution (28), counterproductive to training (29), detrimental to clinical decision making (26), or inappropriately intrusive (26). One study suggested that short-term reductions in the amount of testing were not sustainable (30). In a review of various approaches to limit testing, Solomon and colleagues (24) noted that multifaceted interventions are most likely to succeed. The Institute of Medicine (31, 32) and industry leaders (33, 34) recently advocated the use of information systems to improve health care delivery, especially in the area of care provider order entry (CPOE) (35). Several studies document that computer-based reminders (25, 36-38) and just-in-time decision support (39) improve test-ordering practices. Care provider order entry systems also are an effective way to manage and implement change (38, 40) and can be used to reduce variability in provider behavior (41). Citing an alarming increase in the use of expensive or duplicate testing, the Vanderbilt University Medical Center, Nashville, Tennessee, chartered a resource utilization committee (RUC) to reduce variability in laboratory testing, imaging, and formulary use without restricting access to necessary or reasoned inquiry. Members of the committee included many clinical leaders in the institution (Appendix). The committee first identified specific patterns of excessive resource utilization in the hospital and subsequently devised several interventions using CPOE to reduce repetitive testing. The institutional review board approved the study, and the need for informed consent was waived. Methods Study Sample Vanderbilt University Hospital is a 658-bed tertiary care facility that houses 2 floors of the Vanderbilt Children's Hospital. During the study period (1999 to 2001), more than 10000 orders were placed daily through the use of CPOE systems from 35 of the 37 patient care units; these 35 units cover approximately 600 beds of the hospital. The pediatric and neonatal intensive care units (ICUs) were not using CPOE systems during this interval. The study sample consisted of attending physicians, housestaff, medical students, nurses, advance practice nurses, and other clinical staff at Vanderbilt University Hospital who used CPOE systems. Physicians directly entered 70% of orders, and other members of the patient care team entered the remainder of orders. Care Provider Order Entry Like many systems, our CPOE system processes test orders as follows. First, a provider enters an order with a specified duration of recurrences. Second, the system generates up to 1 week of orders for individual tests. Third, each test is performed as scheduled unless a provider cancels subsequent occurrences. Finally, for recurring orders still active after each week, the software queues up a subsequent week of individual occurrences. Resource Utilization Committee Interventions To determine how and where to intervene, the RUC analyzed past CPOE log files for testing patterns and used bibliographic resources and its own expertise to determine optimal strategies for ordering individual tests. From December 1999 through the study period, during weekly to monthly committee meetings with all RUC members invited, the committee reviewed CPOE summary data that indicated the volume of laboratory, radiology, and cardiology tests that were ordered per month on each hospital ward. This was done prospectively to identify opportunities for intervention and was also done after the intervention to determine effectiveness. (No study intervention described in this paper was changed on the basis of this feedback, although the transition from the first intervention method to the second intervention method was catalyzed by such analysis.) Physician behaviors were not analyzed individually. Simple RUC member consensus after committee discussions determined which interventions to implementinformed by the data, the expertise of the chiefs of the clinical services serving on the RUC (who at times also consulted faculty experts within their departments and the literature), and the informatics faculty members of the RUC (who could speak to feasibility of various proposed CPOE-based interventions). In designing the educational components of the interventions, various RUC members (or their expert faculty designees within their departments) often provided literature-based synopses of evidence that were converted to hypertext markup language (HTML) documents and made available through the CPOE system at ordering time. Individuals creating such documents were responsible for regularly reviewing them to keep their content current. The first RUC intervention was implemented on 5 December 1999 as a broad attempt to reduce open-ended test ordering beyond 72 hours in the future. Each morning, the CPOE system would display a pop-up message that listed orders for scheduled laboratory tests, radiography, and electrocardiography extending beyond 72 hours. The pop-up prompted the provider to choose whether to continue the order, discontinue the order, or defer a decision until later in the day. If the provider chose to continue or discontinue the order, no other provider would receive pop-up reminders about that order until possibly the next day. The second RUC intervention involved several specific ordering constraints. The RUC reasoned that most repetitive orders for routine blood tests, radiology, and electrocardiography could not be justified without an intervening bedside visit. They then developed several specific ordering constraints. First, individual orders were limited to 1 occurrence in a fixed period of time. Second, the metabolic panel was unbundled and could be ordered only as individual components. Third, a graphical display of results from the previous week was placed on the ordering page for frequently ordered serum chemistry tests. This display made it difficult to claim that previous results were unknown at the time when additional tests were ordered. On 20 January 2000, the RUC initiated the second intervention by making all portable chest radiography orders one-time only. Starting on 1 February 2000, electrocardiograms could be ordered only once or twice in 8 hours per individual order. Providers still could order more electrocardiograms or portable chest radiographs by entering additional one-time orders with different start dates and times. On 21 March 2000, the RUC also implemented specific ordering constraints for unbundled components of the serum metabolic panel: Sodium, potassium, chloride, bicarbonate, and glucose tests could be ordered once or at recurring intervals up to hourly but not beyond 24 hours; blood urea nitrogen (BUN) or serum creatinine tests could be ordered only once in 24 hours. Orders for a complete blood count were not constrained during this second intervention period so that the complete blood count test could be used as a control for ordering behavior. Statistical Analysis The RUC examined 2 methods of counting test orders: on the basis of the day tests were first ordered or on the basis of the day tests were intended to occur. Because providers frequently enter orders to discontinue tests, the RUC defined net orders as the number of tests not discontinued before their time of occurrence. Some tests could be ordered as panels, so that a metabolic panel contributed 7 tests (sodium, potassium, chloride, bicarbonate, glucose, BUN, and creatinine tests) to the overall count of ordered component tests, whereas a portable chest radiograph or electrocardiogram counted as 1 test each. The data were evaluated by using interrupted time-series analyses. Patient name, individual ordering provider, and attending physician were not identified as part of the analysis. Each order was assessed in 3 ways to account for all possible outcomes. First, we noted the date that the order was written to determine whether constraining the duration of the order resulted in increased daily ordering. Second, we analyzed the daily number of net orders to approximate the number of ordered tests performed each day. Third, we counted the number of tests resulted in our institutional data repository to determine the actual number of tests performed. We ultimately used orders rather than test results as our primary measure because log file review revealed that net orders for a test closely reflected the actual number of tests performed and because tests ordered during system downtime were not subject to the intervention. The primary outcome was the daily number of new tests ordered and discontinued. Every CPOE order for each targeted test was considered. We ev